Acceptability and Efficacy of a Sexual Health Texting Intervention Designed to Support Adolescent Females

Interventions Promoting Condom Use Among Youth: A Systematic Review

In many European and other high-income, Western countries, condom use has been decreasing among youth. A variety of promotional strategies to increase condom use exists. Our systematic review aimed to identify effective elements in interventions aimed at increasing condom use in youth. We searched databases (2010-2021) for intervention studies promoting condom use among youth in Western, high-income countries. The primary outcome was condom use; the secondary outcome was sexually transmitted infection (STI) diagnoses. Effectiveness per intervention was defined based on the percentage of comparisons that showed significant increases in condom use and significant decreases in STIs. We compared the effectiveness of interventions for different participant-, intervention- and methodological characteristics. We included 74 papers describing 85 interventions in the review. Overall, the median intervention effectiveness was 33.3% (interquartile range = 0%-66.7%) for condom use and 0% (interquartile range = 0%-100%) for STI diagnoses. Intervention effectiveness for condom use was significantly higher in interventions tailored towards females and males specifically, compared with interventions applied to both sexes combined. Our findings show the difficulty in designing effective interventions to increase condom use among youth. Interventions aimed at either females or males were more effective in increasing condom use.

Effects of telehealth interventions for adolescent sexual health: A systematic review and meta-analysis of randomized controlled studies

INTRODUCTION

Telehealth interventions to advance adolescent sexual health have evolved and are being used to promote adolescent sexual health knowledge and healthy sexual behaviors. However, as this area of intervention modality expands, there is a need to pause and examine the effects of telehealth interventions on adolescent sexual health outcomes. Addressing this knowledge gap will inform researchers and practitioners on the current state of evidence of telehealth interventions and inform further intervention development and testing. This study aimed to explore the meta-effects of telehealth interventions on self-efficacy of using condoms, condom use practices, and sexually transmitted infection testing behaviors among adolescents.

METHODS

A systematic review and meta-analysis of randomized controlled trials were conducted. Seven databases (Academic Search Complete, CINAHL, EMBASE, MEDLINE, PubMed, OVID (UpToDate), and Web of Science) were searched for relevant full-text articles from the inception to May 2021. The revised Cochrane risk-of-bias tool for randomized trials was used to assess the methodological quality of the included studies. A meta-analysis was performed using a random effects model to calculate the pooled effects of telehealth interventions for adolescents. Stata 16.0 was used for statistical analysis.

RESULTS

A total of 15 studies (N = 5499) that used telehealth interventions with adolescents were included in the analysis. Telehealth interventions were found to increase self-efficacy for condom use (standardized mean difference: 0.22; 95% confidence interval: 0.08-0.36), practice for condom use (standardized mean difference: 0.35; 95% confidence interval: 0.23-0.47), and being screened/tested for sexual transmitted infections (standardized mean difference: 0.61; 95% confidence interval: 0.31-0.92).

DISCUSSION

Telehealth interventions show promise as effective intervention delivery solutions for improving self-efficacy and certain sexual health behaviors among adolescents. These telehealth strategies could be important alternatives to in-person visits to accessing sexual health information or services near where they live. Future research should consider testing telehealth strategies where there is evidence of impact to move the field forward.

Mobile phone-based interventions for improving contraception use

BACKGROUND

Contraception provides significant benefits for women's and children's health, yet many women have an unmet need for contraception. Rapid expansion in the use of mobile phones in recent years has had a dramatic impact on interpersonal communication. Within the health domain text messages and smartphone applications offer means of communication between clients and healthcare providers. This review focuses on interventions delivered by mobile phone and their effect on use of contraception.

OBJECTIVES

To evaluate the benefits and harms of mobile phone-based interventions for improving contraception use.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was August 2022.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of mobile phone-based interventions to improve forms of contraception use amongst users or potential users of contraception.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcomes were 1. uptake of contraception, 2. uptake of a specific method of contraception, 3. adherence to contraception method, 4. safe method switching, 5. discontinuation of contraception and 6. pregnancy or abortion. Our secondary outcomes were 7. road traffic accidents, 8. any physical or psychological effect reported and 9. violence or domestic abuse.

MAIN RESULTS

Twenty-three RCTs (12,793 participants) from 11 countries met our inclusion criteria. Eleven studies were conducted in high-income resource settings and 12 were in low-income settings. Thirteen studies used unidirectional text messaging-based interventions, six studies used interactive text messaging, four used voice message-based interventions and two used mobile-phone apps to improve contraception use. All studies received funding from non-commercial bodies. Mobile phone-based interventions probably increase contraception use compared to the control (odds ratio (OR) 1.30, 95% confidence interval (CI) 1.06 to 1.60; 16 studies, 8972 participants; moderate-certainty evidence). There may be little or no difference in rates of unintended pregnancy with the use of mobile phone-based interventions compared to control (OR 0.82, 95% CI 0.48 to 1.38; 8 trials, 2947 participants; moderate-certainty evidence). Subgroup analysis assessing unidirectional mobile phone interventions versus interactive mobile phone interventions found evidence of a difference between the subgroups favouring interactive interventions (P = 0.003, I2 = 88.5%). Interactive interventions had an OR of 1.71 (95% CI 1.28 to 2.29; P = 0.0003, I2 = 63%; 8 trials, 3089 participants) whilst unidirectional interventions had an OR of 1.03 (95% CI 0.87 to 1.22; P = 0.72, I2 = 17%; 9 trials, 5883 participants). Subgroup analysis assessing high-income versus low-income trial settings found no difference between groups (subgroup difference test: P = 0.70, I2 = 0%). Only six trials reported on safety and unintended outcomes; one trial reported increased partner violence whilst another four trials reported no difference in physical violence rates between control and intervention groups. One trial reported no road traffic accidents with mobile phone intervention use.

AUTHORS' CONCLUSIONS

This review demonstrates there is evidence to support the use of mobile phone-based interventions in improving the use of contraception, with moderate-certainty evidence. Interactive mobile phone interventions appear more effective than unidirectional methods. The cost-effectiveness, cost benefits, safety and long-term effects of these interventions remain unknown, as does the evidence of this approach to support contraception use among specific populations. Future research should investigate the effectiveness and safety of mobile phone-based interventions with better quality trials to help establish the effects of interventions delivered by mobile phone on contraception use. This review is limited by the quality of the studies due to flaws in methodology, bias or imprecision of results.

Behavioural intervention to reduce sexually transmitted infections in people aged 16–24 years in the UK: the safetxt RCT

Background

The prevalence of genital chlamydia and gonorrhoea is higher in the 16–24 years age group than those in other age group. With users, we developed the theory-based safetxt intervention to reduce sexually transmitted infections.

Objectives

To establish the effect of the safetxt intervention on the incidence of chlamydia/gonorrhoea infection at 1  year.

Design

A parallel-group, individual-level, randomised superiority trial in which care providers and outcome assessors were blinded to allocation.

Setting

Recruitment was from 92 UK sexual health clinics.

Participants

Inclusion criteria were a positive chlamydia or gonorrhoea test result, diagnosis of non-specific urethritis or treatment started for chlamydia/gonorrhoea/non-specific urethritis in the last 2 weeks; owning a personal mobile phone; and being aged 16–24 years.

Allocation

Remote computer-based randomisation with an automated link to the messaging system delivering intervention or control group messages.

Intervention

The safetxt intervention was designed to reduce sexually transmitted infection by increasing partner notification, condom use and sexually transmitted infection testing before sex with new partners. It employed educational, enabling and incentivising content delivered by 42–79 text messages over 1 year, tailored according to type of infection, gender and sexuality.

Comparator

A monthly message regarding trial participation.

Main outcomes

The primary outcome was the incidence of chlamydia and gonorrhoea infection at 12 months, assessed using nucleic acid amplification tests. Secondary outcomes at 1 and 12 months included self-reported partner notification, condom use and sexually transmitted infection testing prior to sex with new partner(s).

Results

Between 1 April 2016 and 23 November 2018, we assessed 20,476 people for eligibility and consented and randomised 6248 participants, allocating 3123 to the safetxt intervention and 3125 to the control. Primary outcome data were available for 4675 (74.8%) participants. The incidence of chlamydia/gonorrhoea infection was 22.2% (693/3123) in the intervention group and 20.3% (633/3125) in the control group (odds ratio 1.13, 95% confidence interval 0.98 to 1.31). There was no evidence of heterogeneity in any of the prespecified subgroups. Partner notification was 85.6% in the intervention group and 84.0% in the control group (odds ratio 1.14, 95% confidence interval 0.99 to 1.33). At 12 months, condom use at last sex was 33.8% in the intervention group and 31.2% in the control group (odds ratio 1.14, 95% confidence interval 1.01 to 1.28) and condom use at first sex with most recent new partner was 54.4% in the intervention group and 48.7% in the control group (odds ratio 1.27, 95% confidence interval 1.11 to 1.45). Testing before sex with a new partner was 39.5% in the intervention group and 40.9% in the control group (odds ratio 0.95, 95% confidence interval 0.82 to 1.10). Having two or more partners since joining the trial was 56.9% in the intervention group and 54.8% in the control group (odds ratio 1.11, 95% confidence interval 1.00 to 1.24) and having sex with someone new since joining the trial was 69.7% in the intervention group and 67.4% in the control group (odds ratio 1.13, 95% confidence interval 1.00 to 1.28). There were no differences in safety outcomes. Additional sensitivity and per-protocol analyses showed similar results.

Limitations

Our understanding of the mechanism of action for the unanticipated effects is limited.

Conclusions

The safetxt intervention did not reduce chlamydia and gonorrhoea infections, with slightly more infections in the intervention group. The intervention increased condom use but also increased the number of partners and new partners. Randomised controlled trials are essential for evaluating health communication interventions, which can have unanticipated effects.

Future work

Randomised controlled trials evaluating novel interventions in this complex area are needed.

Trial registration

This trial is registered as ISRCTN64390461.

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 11, No. 1. See the NIHR Journals Library website for further project information.

Adolescent Perceptions of Technology-Based Sexual and Reproductive Health Services: A Systematic Review

Technology-based services, including telehealth, text messaging, and the internet are increasingly popular methods for adolescents and young adults (AYA) to access sexual and reproductive health (SRH) information and healthcare. This systematic review examined AYA perceptions of privacy and confidentiality of technology-based SRH services. The PubMed, Scopus, and PsycINFO were systematically searched in May 2021 to capture relevant qualitative or quantitative articles from the past 10 years. Included studies had AYA (i.e., mean age, 13-26-years with <10% of the sample outside this range), technology-based services for SRH, and outcomes of perceived privacy or confidentiality. Twenty-eight articles were included (N = 8638 AYA). Most studies utilized the internet and mobile apps to address human immunodeficiency virus infection (HIV), sexually transmitted infections, and general SRH topics. Most AYA reported that these services were private and confidential, with minimal differences across SRH topic addressed. More interactive services had greater concerns (e.g., family or friends seeing notifications). Most AYA considered technology-based SRH to be confidential and private. As technology will likely remain an integrated part of healthcare delivery, improving the privacy and confidentiality of these services can facilitate AYA's independent and autonomous engagement in SRH care, and potentially improve their SRH outcomes.

mHealth Interventions for Contraceptive Behavior Change in the United States: A Systematic Review

Ensuring people have access to their preferred method of contraception can be key for meeting their reproductive goals. A growing number of mHealth interventions show promise for improving access to contraception, but no literature review has identified the effects of mHealth interventions among both adolescents and adults in the United States. The purpose of this systematic review was to describe the format, theoretical basis, and impact of mHealth interventions for contraceptive behavior change (contraceptive initiation and continuation) among people of all ages in the US. A systematic review of the literature was conducted using six electronic databases guided by Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines. Data on study design, frequency, duration, mHealth modality, contraceptive method, behavior change theory, and behavioral outcome were extracted to facilitate comparison. Eighteen studies met eligibility criteria. The majority (11; 61%) used SMS (short message service). Twelve studies focused on contraceptive initiation, most (n = 8) of which also measured continued use over time. The remaining six interventions focused on continuation alone, generally through appointment reminders. Very little contraceptive behavior change was identified across studies. Current mHealth interventions may hold promise for some health areas but there is little evidence that they change contraceptive behavior. Future mHealth interventions should focus on assessing person-centered outcomes, including satisfaction, side effects, and reasons for discontinuation, to best support people to use their preferred contraceptive method.

Sexual health interventions delivered to participants by mobile technology: a systematic review and meta-analysis of randomised controlled trials

BACKGROUND

The use of mobile technologies to prevent STIs is recognised as a promising approach worldwide; however, evidence has been inconclusive, and the field has developed rapidly. With about 1 million new STIs a day globally, up-to-date evidence is urgently needed.

OBJECTIVE

To assess the effectiveness of mobile health interventions delivered to participants for preventing STIs and promoting preventive behaviour.

METHODS

We searched seven databases and reference lists of 49 related reviews (January 1990-February 2020) and contacted experts in the field. We included randomised controlled trials of mobile interventions delivered to adolescents and adults to prevent sexual transmission of STIs. We conducted meta-analyses and assessed risk of bias and certainty of evidence following Cochrane guidance.

RESULTS

After double screening 6683 records, we included 22 trials into the systematic review and 20 into meta-analyses; 18 trials used text messages, 3 used smartphone applications and 1 used Facebook messages as delivery modes. The certainty of evidence regarding intervention effects on STI/HIV occurrence and adverse events was low or very low. There was moderate certainty of evidence that in the short/medium-term text messaging interventions had little or no effect on condom use (standardised mean differences (SMD) 0.02, 95% CI -0.09 to 0.14, nine trials), but increased STI/HIV testing (OR 1.83, 95% CI 1.41 to 2.36, seven trials), although not if the standard-of-care control already contained an active text messaging component (OR 1.00, 95% CI 0.68 to 1.47, two trials). Smartphone application messages also increased STI/HIV testing (risk ratio 1.40, 95% CI 1.22 to 1.60, subgroup analysis, two trials). The effects on other outcomes or of social media or blended interventions is uncertain due to low or very low certainty evidence.

CONCLUSIONS

Text messaging interventions probably increase STI/HIV testing but not condom use in the short/medium term. Ongoing trials will report the effects on biological and other outcomes.

Test@Work Texts: Mobile Phone Messaging to Increase Awareness of HIV and HIV Testing in UK Construction Employees during the COVID-19 Pandemic

Background: HIV poses a threat to global health. With effective treatment options available, education and testing strategies are essential in preventing transmission. Text messaging is an effective tool for health promotion and can be used to target higher risk populations. This study reports on the design, delivery and testing of a mobile text messaging SMS intervention for HIV prevention and awareness, aimed at adults in the construction industry and delivered during the COVID-19 pandemic. Method: Participants were recruited at Test@Work workplace health promotion events (21 sites, n = 464 employees), including health checks with HIV testing. Message development was based on a participatory design and included a focus group (n = 9) and message fidelity testing (n = 291) with assessment of intervention uptake, reach, acceptability, and engagement. Barriers to HIV testing were identified and mapped to the COM-B behavioural model. 23 one-way push SMS messages (19 included short web links) were generated and fidelity tested, then sent via automated SMS to two employee cohorts over a 10-week period during the COVID-19 pandemic. Engagement metrics measured were: opt-outs, SMS delivered/read, number of clicks per web link, four two-way pull messages exploring repeat HIV testing, learning new information, perceived usefulness and behaviour change. Results: 291 people participated (68.3% of eligible attendees). A total of 7726 messages were sent between March and June 2020, with 91.6% successfully delivered (100% read). 12.4% of participants opted out over 10 weeks. Of delivered messages, links were clicked an average of 14.4% times, max 24.1% for HIV related links. The number of clicks on web links declined over time (r = -6.24, p = 0.01). Response rate for two-way pull messages was 13.7% of participants. Since the workplace HIV test offer at recruitment, 21.6% reported having taken a further HIV test. Qualitative replies indicated behavioural influence of messaging on exercise, lifestyle behaviours and intention to HIV test. Conclusions: SMS messaging for HIV prevention and awareness is acceptable to adults in the construction industry, has high uptake, low attrition and good engagement with message content, when delivered during a global pandemic. Data collection methods may need refinement for audience, and effect of COVID-19 on results is yet to be understood.